Nursing Elites

1. A nurse is assessing a client who has a urinary tract infection and is receiving ciprofloxacin. Which of the following findings should the nurse report to the provider?

• A. Dry mouth.
• B. Photosensitivity.
• C. Headache.
• D. Urinary retention.

Correct answer: B

Rationale: The correct answer is B: Photosensitivity. Ciprofloxacin can cause photosensitivity, making the client more sensitive to sunlight. It is essential for the nurse to report this finding to the provider so that appropriate measures can be taken to prevent skin damage. Dry mouth, headache, and urinary retention are not typically associated with ciprofloxacin use and do not require immediate reporting to the provider in this scenario.

2. A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?

• A. Take the medication with a full glass of water.
• B. Take the medication with food to prevent stomach upset.
• C. Take one tablet every 5 minutes, up to three doses, for chest pain.
• D. Swallow the tablet whole for the best effect.

Correct answer: C

Rationale: The correct instruction for a client with a new prescription for nitroglycerin sublingual tablets is to take one tablet every 5 minutes, up to three doses, for chest pain. This dosing regimen helps relieve chest pain associated with angina by promoting vasodilation. Option A is incorrect as nitroglycerin sublingual tablets should be placed under the tongue, not swallowed with water. Option B is incorrect because taking nitroglycerin with food may decrease its effectiveness. Option D is incorrect because nitroglycerin sublingual tablets are meant to be dissolved under the tongue, not swallowed whole.

3. What is the priority intervention for a patient with a severe allergic reaction?

• A. Administer epinephrine
• B. Administer corticosteroids
• C. Administer oxygen
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions because it rapidly reverses the symptoms of anaphylaxis by constricting blood vessels, increasing heart rate, and relaxing airway muscles. Corticosteroids, although helpful to reduce inflammation, are not the priority in the acute management of severe allergic reactions. Oxygen may be needed to support breathing, but it is not the initial priority. Antihistamines are not as effective as epinephrine in treating severe allergic reactions and should not be the first intervention.

4. A nurse is providing discharge instructions to a client who has tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should have my vision checked regularly while taking this medication.
• B. This medication can cause my urine to turn reddish-orange.
• C. I need to wear sunscreen and protective clothing while taking this medication.
• D. I will discontinue this medication if I experience nausea.

Correct answer: B

Rationale: The correct answer is B. Rifampin can cause a harmless reddish-orange discoloration of body fluids, including urine. Choice A is not related to rifampin; vision changes are not a common side effect of the medication. Choice C is more relevant to medications that cause photosensitivity reactions, not specifically rifampin. Choice D is incorrect because nausea is a common side effect of rifampin, but it does not warrant immediate discontinuation of the medication.

5. Which lab value is critical for a patient on heparin therapy?

• A. Monitor aPTT
• B. Monitor INR
• C. Monitor platelet count
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT. Activated Partial Thromboplastin Time (aPTT) is crucial for patients on heparin therapy as it helps determine the clotting ability of the blood. By monitoring aPTT, healthcare providers can adjust the dosage of heparin to maintain therapeutic levels and prevent bleeding complications. Monitoring INR is more commonly associated with warfarin therapy, not heparin. Monitoring platelet count is important for assessing the risk of bleeding or clotting disorders but is not specific to heparin therapy. Monitoring sodium levels is not directly related to assessing the effectiveness or safety of heparin therapy.

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